Download A to Z of Anaesthesia for Elderly Trauma Patients

The A to Z of anaesthesia for elderly NOF/trauma patients
PLEASE NOTE:- these guidelines are not applicable to patients coming for elective surgery.
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Anaesthetists who regularly give anaesthetics for trauma lists have prepared this document.
If you work within these guidelines, patients will usually be accepted for theatre.
The judgement of the anaesthetist on the day over rides anything written here. In particular, if less
experienced anaesthetists are working on their own, patients may still be turned down.
Evidence suggests that reduced time to surgery correlates well with increased survival.
YOU can make the difference!
Analgesia
You will normally prescribe all preop analgesics, and the anaesthetist will usually prescribe all postop
analgesics. Remember, regular paracetamol (1g po qds) is a very effective analgesic. 40% of patients
have eGFR<60: for these – avoid NSAIDs, codeine and tramadol, and reduce the amount of im
morphine given (avoid oramorph) by halving the dose and doubling the dose interval (ie (2.5-5mg im 4
hourly). If you have any queries, the pain team is available on bleep 8102 or out of hours, bleep the 1ston call anaesthetist.
Antibiotics
The BSUHT prophylactic antibiotic policy undergoes periodic review. Currently, a single dose of
cefuroxime 1.5g iv is administered by the anaesthetist at induction of anaesthesia. The hospital antibiotic
policy should be consulted if the patient develops pneumonia, urinary infection etc
Atrial Fibrillation
All patients in AF should have a ventricular rate of less than 100. Regular nursing observations should
include the rate counted at the apex beat, not peripherally. If control is poor: Exclude or treat factors that may lead to new or fast AF. Check potassium and magnesium
levels. Consider hypovolaemia, sepsis, pain, hypoxaemia.
 Trust guidelines suggest the use of beta blockers. Please consider contraindications to treatment
before prescribing. If in doubt, ask *.
 For previously undiagnosed AF, we suggest that intra-venous digoxin gives a reliable effect
within 4 – 6 hours. If you are unsure about the dose, please ask *.
 For patients already on treatment for AF, you should consider exacerbating factors as above, and
then discuss increased treatment with the orthogeriatricians. If the rate is between 100 and 120, it
may be possible to proceed – please discuss with the anaesthetist. If the rate is over 120
more treatment is usually required.
Blood tests
All elderly trauma patients need FBC and Coag, U&E – see the shaded boxes on the Hip Integrated
Care Pathway proforma AND we need the results in the notes by 8 am on the day of surgery!
G&S – all #NOF, all nailings, major joint replacements or revisions, all #long bones
Cross match – only for patients who are likely to need blood (ie admission Hb < 10g/dl, particularly if
undergoing nailing/revision). RSCH has an electronic issue system. This means that you need to send 2
separate blood samples for G+S, ring the lab prior to surgery to check that blood is ready and write in the
notes that ‘the lab have confirmed that this patient is suitable for electronic issue of blood’ (or similar).
And ALSO:RECHECK Hb + U&E according to shaded boxes on the Hip Integrated Care Pathway proforma.
Chest Infections
Chest infection is rarely a reason to cancel a case. Antibiotics should be started promptly. Delaying
surgery to allow a chest infection to improve is usually futile as chest infections get worse, not better in
the presence of a #NOF. Patients with a chest infection can usually have a spinal anaesthetic.
Exceptions to this are: raised INR (more than 1.5)
 rods or other instrumentation of the spine
 patient too breathless to tolerate lying at about 20 degrees from flat severe
 aortic stenosis or critical coronary artery disease (and even then this is negotiable!)
Please let the anaesthetist know if a patient with a chest infection also has one of these conditions.
Patients with chest infections should be listed for the next available daytime slot.
Chest X-Ray
Routine chest X rays on admission are not necessary. Chest X ray may be useful in patients with heart
failure or pneumonia – please discuss with the anaesthetist or orthogeriatrician. Repeat X Ray to assess
a chest infection is rarely of any use.
Clopidogrel
Clopidogrel (Plavix) inhibits platelet function. If a patient is taking clopidogrel it should alert you to elicit
ischaemia in the patient’s cardiac history. Clopidogrel is generally continued during admission. Operation
should not be delayed, nor platelets administered prophylactically. Expect greater blood loss, and order
blood appropriately, taking the opportunity to inform haematology that a clopidogrelled patient is about to
undergo an operation and may require platelets. Monitor for signs of cardiac ischaemia. If in doubt,
consult the cardiology registrar.
Consent
25% of patients will have at least moderate cognitive impairment, and this may affect their ability to
consent to or refuse treatment. NOF is a serious life event (30% of patients will be dead within the year)
and this should be emphasised to relatives/carers. The appropriate consent form should be completed
by an appropriately qualified doctor (usually orthopaedic registrar or senior) before the patient leaves the
ward for theatre.
Correct Site Surgery
An appropriate, indelible mark should be drawn on the patient to indicate the intended surgical site by
the operating surgeon (or nominated deputy) before the patient leaves the ward for theatre.
Creatinine
40% of elderly NOF patients have a raised creatinine + GFR<60 on admission. This may be a very
significant elevation in a small elderly person. It may not prevent the patient going to theatre, but we will
need some additional information. Please seek old results. If new seek the cause. Ensure hydration and
not in retention. Start a fluid balance chart. If chronic, note this on the drug chart in the ‘allergies’ section
on the front. Be very careful prescribing painkillers: opiates – half dose, double interval, give im not po;
NSAIDs, codeine, tramadol – omit.
Diabetes
Detailed guidelines for diabetes are found in the Trust protocol. Most trauma patients can eat and drink
within 4 hours after surgery and plans for control of diabetes should take this into account.
 Insulin dependent patients need to be placed first on the operating list. They usually need a
dextrose and insulin regime started on the morning of surgery.
 Non insulin dependent patients do NOT usually need a dextrose and insulin regime pre-op. They
should be placed as early as possible on the list, fasted, and diabetic tablets omitted. The blood
sugar should be monitored 1-2 hourly. If it rises above 11 you may need to use insulin. Discuss
with orthogeriatricians or the anaesthetist.
 Diet controlled diabetics almost never need a dextrose and insulin regime pre-operatively. Their
blood sugar should be monitored.
High blood sugars are not usually a reason to delay surgery in urgent trauma patients, unless the
patient is ketotic and dehydrated. You should start treatment urgently however and discuss what
you are doing with the anaesthetist.
ECG
ALL elderly trauma patients need an ECG. The following rhythms are of interest: Atrial fibrillation – see earlier note
 Tri-fascicular block. Discuss with cardiology or senior trauma anaesthetist ASAP.
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Complete heart block. Discuss with cardiologist or senior trauma anaesthetist ASAP.
Multiple or multi-focal ectopics, bigemini or trigemini. If no history of blackouts – ensure normal
K+, check and correct Mg++. If history of blackouts – discuss with orthogeriatrics, cardiology or
senior trauma anaesthetist ASAP.
Echo
(These remarks should not be applied to pre-assessment for elective surgery.)
There are two reasons that an anaesthetist may require an echo: to find the origin of a heart murmur (most importantly to exclude aortic stenosis)
 to establish LV function
Murmurs
 Pan sytolic murmurs heard at the apex (mitral regurgitation). These do not need an echo.
 Ejection systolic murmurs heard in the aortic area - need an urgent echo, particularly if there is
evidence that there may be significant aortic stenosis. This is indicated by two or more of the
following, (or one of the following if severe): history of angina on exertion
 unexplained syncope or near syncope
 slow rising pulse clinically (try the brachial pulse for this)
 absent 2nd heart sound
 LVH on the ECG without hypertension
 CXR suggests AS (enlarged heart, post stenotic dilation of aorta)
LV function
 If the patient is known to have heart failure, we do NOT need an echo – we will treat as reduced
LV function.
 If the patient is breathless at rest or on low level exertion, the anaesthetist will need to work out
whether this is due to LV failure or lung disease. If he/she cannot make this diagnosis on clinical
grounds, an echo may help. These patients should be reviewed by an orthogeriatrician or senior
anaesthetist as soon as possible after admission.
Please arrange the echo by contacting the cardiology registrar on ****. The echo service is very good at
RSCH. However, if an echo request appears to be delaying surgery, please rediscuss the need for it with
a senior trauma anaesthetist.
Haemoglobin
We recommend the following guidelines for elderly trauma patients: If Hb is <9g/dl please transfuse up to >10g/dl.
 If Hb is 9 – 9.9g/dl and there is a history of ischaemic heart disease, please transfuse up to
>10g/dl.
 If Hb is 9 – 9.9 and there is no history of ischaemic heart disease, please order 2 units of blood to
be available in theatre.
 If transfused there must be a post transfusion check Hb available.
Heparin
Subcutaneous heparin should be prescribed as in your department guidelines. This is currently
Tinzaparin 4500 units. Thigh-length compression stockings should be prescribed, unless
diabetic/peripheral vascular disease.
Always prescribe LMWH to be given between 18:00 and 20:00. This is because we cannot do a
spinal anaesthetic within 12 hours of a dose. The evening dose allows us to do a spinal at any time
during the next day’s list.
Hip Integrated Care Pathway
This should be the only document you need to write during the management of patients with NOF –
please use it preoperatively and postoperatively, and complete it as comprehensively as possible. If you
don’t write it, it didn’t happen. The HICP is updated every 6 months or so: if you have any suggestions
for improving this document, please email Dr ***** *****.
INR
 The INR should be below 2 for most operations.
 For a spinal anaesthetic the INR must be less than 1.3
For patients on warfarin, please use the flowchart below:
INR
2-6.5
Low risk patient
AF
Recurrent DVT/PE
DVT/PE>3 months
Thrombophilia
High risk patient
Prosthetic Heart Valves
Caval Filters
DVT/Pe<3 months
Tinzaparin s/c
after 4 hours
Vit K
1mg
CHECK INR
at 7am
Start
IV heparin
<1.5
INR
>6.5
Call haematologist of
the week
1.5-2.5
>2.5
2 units FFP
before surgery
Proceed with surgery
 Restart Warfarin 24 hours post surgery, and discontinue heparin when INR is therapeutic.
Intra-venous infusion
All #NOF patients need an IVI. U&E should be monitored alternate days or daily if abnormal.
Living Wills/Advance Directives/Lasting Power of Attorney
Since the enforcement of the Mental Capacity Act, 2005, you must make reasonable efforts to ascertain
whether a patient without the current mental capacity to make a treatment decision has made a valid
living will or has appointed a Lasting Power of Attorney (LPA). If in doubt, or if there are any legal
uncertainties, ask your consultant to contact Ms ***** ***** (x****).
Oxygen
Patients with an oxygen saturation of less than 94% (on air) perioperatively should be administered at
least 2 litres/minute nasal oxygen (5l/min facemask if Sp02 < 90%). Patients with Type 2 respiratory
failure are uncommon amongst NOF patients: consult orthogeriatricians for advice.
Pacemakers
A pacemaker check should usually be requested pre-op, especially if the fall is unexplained. It also helps
us to know the type of pacemaker and the patient’s unpaced rhythm. Please contact the pacemaker
service on **** within normal office hours, explaining that the patient requires emergency surgery.
Platelet count
 If the platelet count is >120, no action is required.
 If the platelet count is 80 – 120 this should be followed up after surgery. It may need
investigating.
 If the platelet count is 50 – 80, this will usually exclude a spinal anaesthetic. The surgeon is likely
to want platelet cover, which should be planned in advance with the haematologist. Ask the lab to
do a blood film – platelets may clump, which can give a misleading low result.
 If the platelet count is below 50, this should be discussed with the haematologist of the week.
Potassium
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Potassium level must be > 3 mmol/dl, or the case will be cancelled.
If the potassium level is between 3 and 3.5, we will accept only if adequate potassium
replacement is in progress.
 If the potassium is less than 3.5 there must be a daily check until it comes up and the cause has
been stopped/treated.
 Remember you can get an instant potassium from the blood gas machine (take a heparinised
venous sample)
Consider why the potassium is low, and treat the cause.
Sodium
Patients with low sodium may have impaired control of sodium and water balance in the brain. This may
lead to cerebral events (including fits, brain swelling and brain damage). Females appear to be more at
risk than males. Also note
 Slow onset or chronic hyponatraemia may be compensated and safe.
 Rapid correction can be unsafe.
Na+ 120 – 130 : Find previous Na+ results if available. Consider cause. Stop inappropriate diuretics.
Avoid IV dextrose. We may accept, especially if evidence that it is chronic. If it has fallen over a short
time (a few days) we may postpone surgery. Please check urine and plasma osmolality, remove the
cause if known and contact the orthogeriatrician. Do not try and give large amounts of sodium.
Na+ <120 – all of the above plus seek orthogeriatric opinion.
Thyroid function tests
These should be done on admission in patients on thyroxine. However if the patient is clinically
euthyroid, we will usually accept the patient for theatre without a result.
And finally:Special Anaesthetic review
Please note we will always want to be warned about patients as follows: History of difficult intubation; anyone who can’t open their mouth; anyone with restricted neck
movement (eg Ankylosing spondylitis) or unstable neck (# or RA)
 Known problems with GA – malignant hyperpyrexia, suxamethonium apnoea, any unplanned ICU
admission in the past
Notes Notes Notes !
If your patient has had relevant treatment which is documented in other notes – please get those notes.
If the notes are not available, please ask the GP to fax a copy of their patient summary.
*Contact Details
 Orthogeriatrician
 Trauma Coordinator
 Trauma theatre
 Anaesthetic Consultant
 Cardiology SpR
 Medical SpR (ward cover)
 Haematologist of the Week
 Orthopaedic wards
Dr **** ****, contact via switchboard
Bleep ****
Main theatres x****
Dr Stuart White x****
Bleep ****
Bleep ****
x****
x****
x****